04 Malignant Skin Lesions

Some of these patients will survive for extended

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Unformatted text preview: om the Sunbelt Melanoma Trial.56 Therapeutic lymph node dissection. Therapeutic lymph node dissection is performed in patients who show evidence of lymph node metastases on physical examination. Some of these patients will survive for extended periods; most will at least be rendered free of the signs and symptoms of nodal metastases.57 Isolated limb perfusion. Most patients with in-transit metastases experience unfavorable outcomes, with 5-year survival rates ranging from 25% to 30%. Surgical excision to clear margins is the mainstay of therapy when the size and number of the lesions permit. Amputation is rarely necessary. A therapeutic alternative to surgical excision for patients who have extensive in-transit metastases in an extremity is the technique known as isolated limb perfusion (ILP).The prime advantage of ILP is that it can achieve high regional concentrations of therapeutic agents while minimizing systemic side effects.58 The arterial supply and the venous drainage are isolated, and a tourniquet may also be used to occlude superficial collateral veins. An oxygenated extracorporeal circuit is employed to circulate a chemotherapeutic agent (typically melphalan) for 1 to 1.5 hours.The temperature of the limb is usually elevated to 39° to 40° C.59 In patients who have clinically positive nodes, therapeutic lymph node dissection is performed in the same setting, just before limb perfusion.The effect of ILP can be dramatic; for example, the rate of complete response with melphalan ACS Surgery: Principles and Practice 4 Malignant Skin Lesions — 8 is 54%.60 Unfortunately, the beneficial effect is often short-lived, with recurrence rates reaching 50% within 1 to 1.5 years after ILP.61 In a 2004 series, the overall 5-year survival rate after ILP was 32%.61 Recurrence after ILP may be treated with surgical excision, though it has also been successfully treated with repeat ILP in patients with extensive disease.62 Adjuvant therapy for stage IIB and III melanoma Radiotherapy. Radiotherapy has been used with some success after therapeutic lymph node dissection in patients with high-risk lesions, resulting in a decreased local recurrence rate63 and a modest survival benefit64 in comparison with historic controls.This modality is typically employed in stage III patients who have poor prognostic pathologic factors (e.g., positive surgical margins, multiple positive nodes, extracapsular spread, or vascular or perineural involvement).65 Interferon therapy. Perhaps the most efficacious adjuvant agent tested to date is IFN-α2b, which is currently approved by the United States Food and Drug Administration for adjuvant treatment of stage IIB and stage III melanoma. Although a trial reported in 1996 found that 1 year of high-dose IFN-α2b therapy led to a prolonged relapsefree interval and improved overall survival,66 subsequent trials and a meta-analysis did not confirm this overall survival benefit.67 Furthermore, nearly all patients experience adverse effe...
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This note was uploaded on 03/21/2011 for the course ONC 01 taught by Professor Dzodic during the Spring '11 term at Multimedia University, Cyberjaya.

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